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New to Neurovascular Surgery-Specialty Coding

SPECIALTYCODING

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Hi,

I'm new to NV surgery and would like to have someone who specializes in this field look over my coding. It's greatly appreciated!

Codes I'm thinking
61624
36226 50, 36224 50, 36227 50, 75894 26, not sure how many times I can code 75898 26, maybe 5? Also 76377,26


NOTE: Please bill this exam with a -22 modifier due to the use of multiple catheters and devices, the use of two microcatheters to aid with the embolization procedure, as well as the case taking more than twice the expected working time.


TECHNIQUE: After the risks, benefits, treatment options and complications were discussed with the patient and family and they agreed to proceed, the patient was brought to the angiography suite. Time out was performed. The right groin region was prepped and draped in the usual sterile fashion. A 7 french sheath was placed over a 0.035" PTFE floppy wire in right common femoral artery using Seldinger technique with imaging of the common iliac artery confirming sheath placement. 3000 units of intravenous heparin and intermittent boluses were administered to maintain an ACT 2 - 2.5 times the patients baseline.

A 071 Benchmark guide catheter with a Berenstein insert in conjunction with a 0.038" angled guidewire was used to selectively catheterize the right common carotid artery, right external carotid artery, right internal carotid artery, right vertebral artery, left common carotid artery, left external carotid artery, left internal carotid artery and left vertebral artery. After each vessel was selected multiple AP, lateral, oblique and magnified angiographic runs were performed with filming over the head and neck. Additionally, 3-D rotational angiography was also performed on the left internal carotid artery and images were reconstructed and interpreted on an independent Leonardo work station under concurrent supervision. This was necessary to optimally evaluate the anatomy and create working views. 10 mg of Verapamil was administered to the right internal carotid artery and the left vertebral artery.

EMBOLIZATION:

The left internal carotid artery was selected and under roadmap guidance and 10 mg of verapamil was administered. The 071 Benchmark guide catheter with a Berenstein insert was advanced over the guidewire into the petrous segment of the internal carotid artery. The Berenstein insert and guidewire were removed. Follow-up control angiography was performed which is unchanged from the initial angiogram and demonstrated no vasospasm around the guide catheter.

Under roadmap control, an SL-10 microcatheter was advanced over a Synchro-2 guidewire into the anterior communicating artery aneurysm.

Coil embolization of the aneurysm was performed by advancing a 2.5 mm x 4 mm Target 360 Ultra coil into the aneurysm. Control angiography demonstrates the coil to be well seated in the aneurysm sac and the parent vessel to be widely patent. A second SL-10 microcatheter was advanced over the Synchro-2 guidewire into the anterior communicating artery aneurysm.

Further coil embolization of the aneurysm was performed by advancing the following coils into the aneurysm sac via the second microcatheter:
2 mm x 4 mm Target 360 Ultra
(1 mm x 3 mm Target 360 Ultra)
(1 mm x 3 mm Target 360 Ultra)

The second microcatheter was removed. Via the first microcatheter, coil embolization was performed by advancing the following coils into the aneurysm sac:
(1.5 mm x 4 mm Target 360 Ultra)

Following coil embolization, there was incomplete occlusion of the aneurysm. Control angiography following an embolization demonstrated no evidence of branch vessel occlusion. All catheters were removed. Hemostasis was attained at the entry site by Starclose.


FINDINGS:
RIGHT COMMON FEMORAL ARTERY: There is no evidence of iatrogenic injury.

RIGHT VERTEBRAL ARTERY: There are normal arterial, capillary and venous phases. The right vertebral artery terminates in PICA.

RIGHT COMMON CAROTID ARTERY: The carotid artery bifurcation is at the C3/4 level. The carotid bifurcation is widely patent without atherosclerotic disease or hemodynamic significant stenosis. The cervical internal and external carotid arteries are of normal course and caliber.

RIGHT EXTERNAL CAROTID ARTERY: The vessels are of normal course, caliber and taper regularly. No aneurysm, focal area of stenosis or early draining vein is seen to suggest a fistula.

RIGHT INTERNAL CAROTID ARTERY: There are normal arterial, capillary and venous phases. The posterior communicating artery is small, fills the posterior cerebral artery and rapidly clears from competitive flow. The contralateral anterior cerebral artery flash fills via the anterior communicating artery, with brief opacification of an anterior communicating artery aneurysm. No evidence of vasculitis, branch block or AV shunting is seen. There are no areas with absent capillary blush. Major venous sinuses are patent. There is moderate vasospasm of the right anterior cerebral and middle cerebral arteries

LEFT VERTEBRAL ARTERY: There are normal arterial, capillary and venous phases. Bilateral posterior communicating arteries fill and rapidly clear from competitive flow. No evidence of vasculitis, aneurysm, branch block or AV shunting is seen. There are no areas with absent capillary blush. Major venous sinuses are patent. There is moderate vasospasm of bilateral posterior cerebral arteries.

LEFT COMMON CAROTID ARTERY: The carotid artery bifurcation is at the C3/4 level. The carotid bifurcation is widely patent without atherosclerotic disease or hemodynamic significant stenosis. The cervical internal and external carotid arteries are of normal course and caliber.

LEFT EXTERNAL CAROTID ARTERY: The vessels are of normal course, caliber and taper regularly. No aneurysm, focal area of stenosis or early draining vein is seen to suggest a fistula.

LEFT INTERNAL CAROTID ARTERY: There are normal arterial, capillary and venous phases. The posterior communicating artery is small, fills the posterior cerebral artery and rapidly clears from competitive flow. The contralateral anterior cerebral artery flash fills via the anterior communicating artery. No evidence of vasculitis, branch block or AV shunting is seen. There are no areas with absent capillary blush. Major venous sinuses are patent. There is a 3.5 mm x 4 mm bilobed anterior cerebral artery aneurysm.

LET INTERNAL CAROTID ARTERY (POST GUIDE PLACEMENT): Angiography is unchanged from the initial angiogram, there is no vasospasm around the guide catheter, branch occlusions or areas absent of capillary blush.

LEFT INTERNAL CAROTID ARTERY (POST COIL #1 DEPLOYMENT): Coil mass seated in the anterior communicating artery aneurysm with decreased opacification of the aneurysm dome.

LEFT INTERNAL CAROTID ARTERY (POST COIL #2 DEPLOYMENT): Coil mass seated in the anterior communicating artery aneurysm with decreased opacification of the aneurysm dome.

LEFT INTERNAL CAROTID ARTERY (POST COIL #4 DEPLOYMENT): Coil mass seated in the anterior communicating artery aneurysm with decreased opacification of the aneurysm dome.

LEFT INTERNAL CAROTID ARTERY (POST COIL #5 DEPLOYMENT): Coil mass seated in the anterior communicating artery aneurysm with no further opacification of the aneurysm dome.

LEFT INTERNAL CAROTID ARTERY (POST EMBO CONTROL): Coil mass seated in the anterior communicating artery aneurysm with no further opacification of the aneurysm dome.

LEFT INTERNAL CAROTID ARTERY (FINAL CONTROL): There are normal arterial, capillary and venous phases. The posterior communicating artery is small, fills the posterior cerebral artery and rapidly clears from competitive flow. The contralateral anterior cerebral artery flash fills via the anterior communicating artery. No evidence of vasculitis, branch block or AV shunting is seen. There are no areas with absent capillary blush. Major venous sinuses are patent. Coil mass seated in the anterior communicating artery aneurysm with no further opacification of the aneurysm dome, but residual neck (Raymond 2)

IMPRESSION:
1. Successful coil embolization of a ruptured anterior communicating artery aneurysm. (Raymond 2)
2. Moderate vasospasm of the right and left middle and anterior, as well as bilateral posterior cerebral arteries treated with Verapamil injection.
 
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